Micropigmentation Application

MICROPIGMENTATION APPLICATION Phone 905-565-5565 Ext 120 Cell 416-388-8918 Leon Levi [email protected]

Brokerage Name: Broker Telephone: Fax: E-mail:

Business Name: Location Address: City: Prov.: P.C.: Mailing Address: City: Prov.: P.C.: Owner/Operator: Bus.#: ( ) - Fax: ( ) - Email: Cell #: ( ) - Res.#: ( ) - Alternate Contact: Phone: Email: (If Applicable)

Expiry Date of Current Policy: Current Insurance Company: Number of years in business? Have you ever been cancelled for nonpayment?

LIABILITY INFORMATION Liability Limit Requested: $2,000,000 $3,000,000 $4,000,000 $5,000,000

DESCRIPTION OF OPERATIONS Eye Liner (Top &/or Bottom Lids) Eye Brows Lips Areolas &/or Scars Semi-Permanent (Lash Tinting/Extensions) Other (Please Describe): TOTAL GROSS ANNUAL RECEIPTS: $ Any client under the age of 18? Do parents stay on premise? Do you ever serve alcohol? Do you have a liquor license? Do any specialists provide additional services? Describe: Are any operations or activities done away off premises? Describe: Describe sterilization/cross-contamination prevention procedures:

STAFF (Including Owner/Operators, Employees & Sub-Contractors) Name Yrs of Exp. Type Of Certification (Must attached Certificates) F/T or P/T

EQUIPMENT Make & Model of Machine Used? Do You Have Modified/Rebuilt/Used Equipment? If Yes, % used: % Age: Is Equipment Inspected Daily? Who Does Maintenance? Manufacturer(s) Of Pigment Used: Are All Machines & Pigments Manufactured Within North America?

Micropigmentation Application Page 1 of 2 MICROPIGMENTATION APPLICATION Phone 905-565-5565 Ext 120 Cell 416-388-8918 Leon Levi [email protected]

ADDITIONS TO THE POLICY

ADDITIONAL INSURED (i.e.: landlord)

CLAIMS HISTORY Has the company &/or staff had claims against them in last 5 years? , If yes please list details:

Date Of Loss: Payout: Expenses:

I understand and agree that any policy issued will be based upon the information contained in the application and any related forms. I understand that any forms or other material submitted with the application constitute part of my application for insurance. I further understand and agree that any misrepresentation or failure to provide true and accurate information may result in the voiding of and/or denial of claims under any policy issued at the option of the company.

Applicant: Signature: Title: Date:

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